d. A senior nurse complains to you that one of the junior doctors involved in this case has been caught stealing a box of ciprofloxacin. A formal incident report has been filed and the nurse wants you to “deal with the JMO”. The doctor says he only wanted to take some as prophylaxis against possible meningococcus.

What key principles should you consider in your discussion with the JMO?

64. A 30 year old man presents with a left sided spontaneous pneumothorax.
a. What are 3 features to elicit on evaluation that will help determine your management? (3 marks)
primary/secondary (underlying lung disease), symptomatic, size >2cm or >20% depending on guidelines used
b. Give a clinical circumstances in which each of the following would be appropriate. (3 marks)

66. A 42-year-old man is brought to your ED by ambulance with acute confusion. His wife states that he is previously well and on no medications, but his health has been deteriorating for three months, with tiredness and 10kg weight loss despite an enormous appetite. She also states that, on the bright side, he has become completely impervious to the cold and the extra money they’ve spent on groceries has been saved on heating bills.
Observations are:

67. A 40-year-old female has been brought in following increasing confusion and agitation at home this morning. She has had no other symptoms. She is day 3 after normal vaginal delivery of a healthy baby at another hospital, but her antenatal history is unknown.
Ambulance officers report a generalised tonic-clonic seizure in the ambulance which required 5mg IV midazolam to terminate, followed by ongoing drowsiness and confusion. On arrival in the ED she begins to seize. ED staff and ambulance officers activate the ‘arrest call’ button and transfer her to the Resuscitation Room.
When you arrive she is being nursed on a bed and a provisional trainee is supporting her airway with jaw thrust. Her intravenous cannula has tissued.
On examination:

Airway: snoring / partly obstructed

RR 40 /min

O2 saturations 95%

HR 130 /min

BP 180/100 mmHg

Generalised tonic-clonic seizure

Afebrile
a. List the causes of seizure you would consider in this patient. (4 marks)

Seek and treat a cause from the list above, esp eclampsia (see drugs in Q3)

Get help:

Obstetrics, renal / neurology, ICU

c. If you suspect eclampsia, what initialdrugs/ dose/route/rate would you administer? (2 marks)

Magnesium sulphate: officially 4G IV over 30 mins is RNS OG policy, but it comes in 10mmol amps. Closest is 20mmol (=5G). Safe enough to give over 20 mins provided you dilute it and watch the BP. Followed by IV infusion.

Hydralazine: 5mg IV over 10 mins, can repeat.

68. You are the director of a tertiary ED which is a level one trauma centre. Recently the directors of trauma and haematology have both written to you regarding your department’s haphazard use of blood products in the severely injured. You search your intranet and realise that you do not have a policy.
a. What are 3 triggers for massive transfusion? (3 marks)
Massive Haemorrhage with shock or anaemia, ie Immediate need for uncrossmatched blood due to rapid haemorrhage and anaemia

Blood loss exceeding 150 mL/min

Need for at least 4 RBC units in the setting of uncontrolled bleeding

Replacement of 50% of total blood volume within 3 hours (pprox.. 35mL/kg in an adult)

Coagulopathy in the setting of blood transfusion

b. Name 4 physiological or biochemical parameters that should be measured early and often. (2 marks)
• Temperature;

• Acid–Base Status;

• Ionised Calcium;

• Haemoglobin;

• Platelet Count;

• PT/INR;

• APTT; and

• Fibrinogen Level.

c. What is the indication for Cryoprecipitate delivery? (2 marks)
Cryoprecipitate is used primarily as a source of fibrinogen (but also contains FVIII, VWF and FXIII). This is found in adequate amounts in FFP, and in dilutional coagulopathy FFP alone may be adequate. Coexisting DIC may increase fibrinogen requirements. Empirical use is unnecessary. Use should be guided by fibrinogen determinations.d. What are the targets for Hb, Platelets and INR in massive transfusion? (3 marks)
Hb>80g/L;

Platelets >50x109/L; and

PT and APTT<1.5 x control.

69. A 14 month old girl presents via ambulance to your tertiary ED. She was eating a sausage when she appeared to choke and turn blue. Parental back blows were given.
On arrival the child is drooling, has mild respiratory distress, is upset and has Sats of 96% on 6L 02, a RR of 34 /min and a mild stridor.
A neck x-ray has been done and is shown below.
a. What is the major abnormality on the neck x-ray? (2 marks)
Large radio opaque FB (Snag) in allecular and partially occluding upper airway
b. List and justify 3 options to managing her airway issue. (6 marks)

1. Straight to OT with ENT/paeds anaes: has airway now, prob safest, could go bad on way up to OT, may not be possible if in small place

2. ED RSI : if loses airway needs first aid (back blows) then direct laryngoscopy with magills for FB removal; should be achievable in all EDs (backup Cric)

needs to be escorted by paramedics able to respond if arrhythmia and remain monitored

Depending on location and timing road vs air

72. A 58 year old Chinese Australian woman presents with fatigue. On examination she has a pulse of 95 /min, BP 100/45 mmHg and sats of 98% RA. She is afebrile. She appears deeply jaundiced.
Bloods are done and appear below

73. A 55 year old man comes into ED with a history of gastroenteritis for 4 days.
His ECG is shown below.

a. What is the most important abnormality? (1 mark)

Long QT
b. List 3 important features to obtain from the history of presenting complaint. (2 marks)
Medication history esp macrolides; antipsychotics; antihistamines, antiarrhythmics, antidepressants; diuretics

Support BP: fluids then pressors as likely neurogenic shock (must have pressor available if not given pre induction). Induction drug must be HD Ok (eg ketamine fentanyl, not big dose props)

Mandatory backup surgical option considered

Options depend on access in institution ; thus OT with fibreoptic/gas; definitie trache primarily with ENT; glidescope in ED with bougie etc. Consider other injuries in decision making

75. You are the director of an urban district ED. Your short stay unit has been suffering with prolonged length of stays and high admission rates.
a. List 5 contributing factors to these issues. (5 marks)
Inappropriate pt selection: ; Lack of senior oversight; lack of clear guidelines for use; use as holding ward for admitted pts; lack of allied health/multidisc input; community support options eg respite NH places etc; ambulance delays ; social factors in ED population; staff training inadequate; nursing support /staffing levels; inpatient team access to admitting power; lack of SOPS for common conditions
b. Outline the key steps in improving the short stay unit’s length of stay and admission rates. (5 marks)
Start with overview of current process; review existing literature; review hospital/obs unit policies as stand; consult major stakeholders then

76. A 35 year old woman arrives after being brought in by friends due to her altered level of consciousness. Last seen 4 hours ago. They state she has been upset recently and has been commenced on 2 new medicines by her GP. Her GCS is 10, P 130 /min, BP 102/44 mmHg. She is Afebrile.
a. List 4 key ECG features you would look for on initial assessment and justify those. (4 marks)
Wide QRS (Na channel blocking drugs); long QTc (K+ blockers; antidepressants, antipsychotics); R wave positive in avR or deep S in 1 (na channel blockers);; ST-T changes (SAH, ICH); P waves vs AF vs SVT (tachycardic P130); Congenital abnormalities eg Brugada; HCM

d. Outline your major goals of management. (5 marks)
Requires intubation and ventilation; followed by urgent CTbrain to exclude head injury/CVA; followed by blood transfusion/coagulopathy correction and urgent endoscopy; needs lactulose, avoid large volumes sodium; Start PPI, consider octreotide if known varices.; ceftriaxone Also needs family discussion as very unwell . disposition ICU under gastro

78. A 72 year old man comes in with change in facial appearance and mild headache.

81. An 18 year old factory worker is rushed to ED having sustained a chemical burn to his eye. He thinks the chemical had ammonia in it. It is now 20 minutes since the accident.
His eye is pictured here.

a. Describe the picture. (3 marks)
There is marked clouding/opacification of the entire cornea, limbal ischaemia (must note), conjunctival haemorrhage, swelling, inflammation, inflammation of the eyelid tissues. These features are consistent with a significant/severe alkali corneal chemical burn.

(4 marks) way too much for 4 marks! Must include something from each Hx/exam/Ix, some assessment of severity and Ix for pneumothora

84. A 1 year old presents to your ED with a history of a few days of fever and general unwellness.
A picture of his hand is attached.
a. List 4 differential diagnoses for this patient. (4 marks)
1. Kawasakis disease

86. A 50 year old woman presents to ED with a 4 days history of malaise, intermittent fever, and the rash depicted here.

a. Describe this rash. (3 marks)
Picture of left hand palmar aspect

Multiple haemorrhagic lesions along the palmar aspects of fingers – appearance of petechiae or purpura, suggestive of septic emboli.

The diagnosis is Janeways lesions, indicative of sub-acute bacterial endocarditis.
b. List 4 important examination findings that would be relevant in this case. (4 marks)
1. Elevated temperature – may be intermittent

c. Name the 4 most relevant investigations that you would perform in the ED. (4 marks)
Blood cultures

FBC

ESR/CRP, inflammatory markers

?coagulation screen

?Echocardiogram – debate as to whether this is a ED Ix – would preface by saying if signs acute valvular dysfunction or cardiac comprimise

87. A 41 year old man is brought in by ambulance with a one hour history of palpitations associated with chest discomfort. His GCS is 15 and BP 90/60 mmHg.
His ECG is attached.
a. What is the most likely diagnosis? (1 mark)
VT
b. What features on history and ECG are supportive of your diagnosis? (3 marks)
Hx – age over 35

c. Name one algorithm or diagnostic criteria that you use clinically when interpreting an ECG such as this one. (1 mark)
A number of algorithms – Brugadas, ultra-simple Brugadas,….see LITFL VT page, great reference
d. Briefly outline your immediate management priorities. (5 marks)
VT with pulse, unstable patient by AHA criteria (hypotensive, chest pain), treat as per ARC or ILCOR guidelines

1. In resus, attention to airway, breathing, high flow pre-oxygenation

Consider chemical reversion while preparing if patient stabilises – amiodarone 300mg IV over 20min, then infusion 900mg over 24hr, or second line if DC CV fails or arrhythmia recurs(not sotalol as hypotensive)